Medical Reimbursement Form for Railway Employees and Railway Pensioners

Medical Reimbursement Form for Railway Employees in Service and for pensioners under RELHS – To be used for external hospitals

Northern Railway has published the Reimbursement Form for claiming the medical expenses incurred for Railway Employees, under RELHS and their dependants at Hospitals other than Railway Hospitals or mobile health units of Railway.

Following documents should be attached with this proforma :-(i) Employees/Retired Employees Application giving circumstances under which he/she took treatment.(ii) Photo copy of Medical/RELHS I.D. Card (duly attested by a Gazetted Officer)

(iii) Essentiality certificate issued by the treating doctor of hospital countersigned by Medical Supdt. of the treating hospital.

(vi) Detailed item-wise break-up of all-the bills (this means all bills/vouchers submitted at (v) above should be reproduced in Legible manner) for e.g. :-.Bill No……… Name of Chemist/Shop…………………..Date …………….

S.No.

Description of item

Oty.

Price

Rs. P.1. 2. 3. 4.

Total

(vii) In case of referred cases, attach original referred slip.

(viii ) Instruction for submission :-

In referred cases, the application duly countersigned by Controlling Officer/Subordinate Incharge should be submitted to the Medical Establishment from where he/she was referred.

In un-referred cases, the application duly countersigned by Controlling Officer/Subordinate Incharge should be submitted to the ‘P’ Branch concerned, to the cell set-up for the purpose of handling Medical Reimbursement case.

(For Official Use only)

ln case of all cases being sent to Board.

In case of AGM’s sanction for unreferred/Non Govt. unrecognised cases.

Verbatim view of C.M.D.

Verbatim view of FA & CAO

Signature of C.P.O.

DETAIL OF DATE WISE/ITEM WISE BREAK UP OF ALL THE BILLS OF

(Name of Patient……… . ….. )

Sr No

Date

Bill No

Name of Chemist/Firm

Description of Item .

Quantity

Price

Signature of the Medical Officer Signature of the Medical Officer/Incharge of